Expedite testing of mother as soon as practicable and if test is positive, a) intrapartum antiretroviral (ARV) prophylaxis should be initiated immediately if mother is still in labour and b) infants should receive an ARV regimen that is appropriate for infants who are at higher risk of perinatal HIV transmission as soon as practicable, pending results of supplemental HIV testing.
The Australian Government Department of Health has a National Clinical Assessment Framework for children and young people in out-of-home care. This involves a tiered approach to assessments conducted by their primary health care provider during which a clinical assessment for HIV infection, evaluation of the risk of HIV infection and role of testing for HIV will be undertaken.
a The term “expedited” is used to designate HIV testing performed in situations when a very short turnaround time is optimal. Expedited testing is dependent on the available HIV tests in each facility and may include antigen/antibody immunoassays, antibody-only assays, or HIV nucleic acid tests; see Approved HIV Tests in the text below.
Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = One or more randomized trials in children† with clinical outcomes and/or validated endpoints;
I* = One or more randomized trials in adults with clinical outcomes and/or validated laboratory endpoints with accompanying data in children† from one or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; II = One or more well-designed, nonrandomized trials or observational cohort studies in children† with long-term outcomes; II* = One or more well-designed, nonrandomized trials or observational studies in adults with long-term clinical outcomes with accompanying data in children† from one or more similar nonrandomized trials or cohort studies with clinical outcome data; III = Expert opinion
†Studies that include children or children and adolescents, but not studies limited to postpubertal adolescents
HIV Testing in Pregnancy
The Australian Government Department of Health and Aged Care Pregnancy Care Guidelines recommend routinely offering and recommending HIV testing at the first antenatal visit with a system of clear referral pathways to ensure pregnant people who are diagnosed with HIV infection are managed and treated by the appropriate specialist teams.
No such mandatory newborn testing exists in Australia.
In Australia, testing should be performed by a NATA-accredited laboratory.
Australian healthcare providers can refer to The Optimal Scenario & Context Of Care: Guidance For Healthcare Providers Regarding Infant Feeding Options For People Living With HIV for guidance on infant feeding.
HIV infection should be identified before pregnancy (see Prepregnancy Counseling and Care for Persons of Childbearing Age With HIV) or as early as possible in pregnancy. In the United States, approximately 20% to 34% of infants with perinatal HIV exposure were born to people whose HIV diagnosis was not known before pregnancy.1 Early diagnosis provides the best opportunity to improve the pregnant person’s health and pregnancy outcomes and to prevent infant acquisition of HIV. Universal voluntary HIV testing is recommended as the standard of care for all pregnant people in the United States by the Panel on Antiretroviral Therapy and Medical Management of Children Living With HIV and the Panel on Treatment of HIV During Pregnancy and Prevention of Perinatal Transmission (the Panels), the Centers for Disease Control and Prevention (CDC), the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the U.S. Preventive Services Task Force.2-6 Providers should be aware that gaps in maternal HIV testing do occur and can contribute to missed opportunities for preventing perinatal HIV transmission.7-10
All HIV testing should be performed in a manner that is consistent with state and local regulations. CDC recommends the “opt-out” approach, which is allowed in many jurisdictions and involves notifying a pregnant person that HIV testing will be performed as part of routine care unless they choose not to be tested.2 The “opt-in” approach involves obtaining specific consent before testing, and this approach has been associated with lower testing rates.11,12 Despite the guidelines for universal HIV screening of pregnant people, recent studies indicate that fewer than 80% of women report having been tested for HIV during pregnancy.13,14 The mandatory newborn HIV testing approach, which has been adopted by several states, involves testing newborns with or without maternal consent. In some areas, this applies to all newborns; in others, it applies only to the infants of mothers who have declined prenatal or intrapartum testing.
There are multiple U.S. Food and Drug Administration (FDA)-approved tests available for the diagnosis of HIV infection. Clinicians should familiarize themselves with the testing available at their facilities, including the turnaround time for receiving results. For the purposes of this section, three types of testing are discussed: antigen/antibody immunoassays; antibody only immunoassays; and HIV nucleic acid tests (NAT).
- Antigen/antibody immunoassays: Most routine laboratory testing for HIV currently uses antigen/antibody tests. Because these tests also detect HIV p24 antigen, they can detect acute HIV infection as early as 1 to 2 weeks after appearance of HIV RNA and before appearance of HIV antibody. These tests also detect HIV-2 infection. Laboratory-based tests require trained laboratory staff, and results can be available within 1 hour, but in some hospitals the test may not be readily available 24 hours a day. One FDA-approved antigen/antibody test can be performed at the point of care (POC) and provides results within 30 minutes.
- Antibody-only immunoassays: Many antibody-only immunoassays in current use can be performed using blood from a finger stick or oral fluid and provide results within 30 minutes. Because of this very short turnaround time, they are often referred to as rapid tests. Many of these tests are also approved by the FDA for POC usage. Because these tests detect only antibody, acute HIV infection may be missed.
- HIV NAT: HIV-1 NAT tests detect HIV virus in blood. Depending on the type of HIV NAT, they may detect acute HIV infection, help diagnose HIV infection, and assess response to HIV therapy. Depending on the test, receiving results of an HIV-1 NAT may take several days. The HIV RNA assay is the preferred NAT for possible acute infection and perinatally acquired infection.
In this section, the term expedited is used to designate testing performed in situations when a very short turnaround time is optimal, such as when a mother is in labor but HIV status is undocumented. Expedited testing should be available in all delivery units 24 hours a day, and results should be available within 1 hour. Expedited testing is dependent on the available HIV tests in each facility and may include any of the three test types.
The Panels recommend that clinicians initiate HIV testing with an immunoassay that can detect HIV-1 antibodies, HIV-2 antibodies, and HIV-1 p24 antigen (referred to as an HIV antigen/antibody immunoassay). The Panels’ recommendations for HIV testing are based on CDC’s 2014 Laboratory Testing for the Diagnosis of HIV Infection: Updated Recommendations.15
Individuals with a reactive antigen/antibody immunoassay should be tested further with an HIV-1/HIV-2 antibody differentiation assay (referred to as supplemental testing). Individuals with a reactive antigen/antibody immunoassay and a nonreactive differentiation test should be tested with an FDA-approved plasma HIV RNA assay to assess for acute HIV infection (see CDC’s 2018 Quick Reference Guide: Recommended Laboratory HIV Testing Algorithm for Serum or Plasma Specimens).
In some clinical settings, initial testing may be conducted with a rapid HIV test which detects only HIV antibodies. Clinicians should assess a pregnant person’s risk of acute HIV infection, particularly late in pregnancy, because people may receive a negative result for HIV immunoassays when they are in the window period (the time between infection and when the infection can be detected by a specific laboratory test). The antigen/antibody immunoassay may detect infection as early as 18 days after infection; antibody-only assays (such as rapid tests) may take as long 45 days. However, during this period, the person with acute HIV will be viremic,16 with a high risk of perinatal transmission to the newborn. The HIV RNA assay can detect the presence of HIV as early as 10 days post-infection. When acute HIV infection is suspected during pregnancy, during the intrapartum period, or while breastfeeding, a plasma HIV RNA assay should be performed in conjunction with an antigen/antibody immunoassay. See Early (Acute and Recent) HIV Infection for more information.
Timing and Benefits of HIV Testing in Pregnancy
Maternal HIV testing should be performed as early as possible during pregnancy, wherever a person seeks care (including emergency departments and prenatal clinics), to avoid missed opportunities to identify pregnant people with HIV. Repeat HIV testing should be performed in the third trimester for people who are at increased risk of acquiring HIV or who are living in areas of high HIV incidence. Repeat testing is also recommended when pregnant individuals are diagnosed with sexually transmitted infection (STI), or when they show symptoms and signs of acute HIV infection. Pregnant people with unknown or undocumented HIV status who present to care in labor should be tested before delivery or as soon as possible after delivery.7-10 Because women are more susceptible to HIV acquisition during pregnancy and the postpartum period,17 HIV testing provides an opportunity for clinicians to initiate a discussion about preventive interventions, including educating and counseling about pre-exposure prophylaxis (PrEP) for a pregnant person without HIV who is at risk for acquiring HIV. See Pre-Exposure Prophylaxis (PrEP) to Prevent HIV During Periconception, Antepartum, and Postpartum Periods and guidance available on CDC’s Pre-Exposure Prophylaxis (PrEP) page for more information.
Determining an individual’s HIV status before they become pregnant or during the antenatal period enables—
- People with HIV to receive appropriate antiretroviral therapy (ART) and prophylaxis against opportunistic infections;
- Initiation of treatment in the identified people to maintain and improve their health and to decrease risk of HIV transmission to their fetus and their partners2,18,19;
- Referral of partners for testing, which allows the partners to initiate either treatment if the results are positive or preventive interventions, including PrEP, if the results are negative (see Pre-Exposure Prophylaxis (PrEP) to Prevent HIV During Periconception, Antepartum, and Postpartum Periods);
- Counseling of pregnant people with HIV about recommended modes of delivery based on individualized risks of perinatal transmission of HIV20-22;
- Provision of an appropriate antiretroviral (ARV) drug regimen to the newborn to reduce the risk of perinatal transmission;
- Counseling regarding infant feeding for individuals with HIV (see Infant Feeding for Individuals With HIV in the United States); and
- Early diagnostic evaluation of infants exposed to HIV (see Diagnosis of HIV Infection in Infants and Children), as well as testing of other children, to permit prompt initiation of ART and any indicated prophylaxis measures.3,23-25
Discordant or False Positive HIV Tests
Discordant HIV testing results can be occur, requiring careful evaluation and often repeat tests. Early in HIV infection, before HIV seroconversion, the test combination of a positive antigen/antibody screen, negative HIV-1/HIV-2 antibody differentiation assay, and positive HIV RNA assay may be seen. This combination of results can occur because the immunoglobulin G–based antibody differentiation assay is positive later in infection than the antigen capture or the immunoglobulin M result in the antigen/antibody screen.
False-positive results do occur with HIV testing. The frequency of false-positive HIV testing is dependent on the prevalence of HIV in the population so may vary considerably. In a large urban hospital in Dallas, 21,163 women were screened using a combination antigen/antibody immunoassay and following the supplemental testing strategy recommended by the CDC algorithm. Of the 190 who tested positive, 28 were determined to have false-positive HIV yielding a positive predictive value of 83% (95% confidence interval [CI], 77-88%) and a false positive rate of 0.16% (95% CI, 0.11-0.22%), using the ARCHITECT HIV Ag/Ab assay.26 For women screened a second time in pregnancy, the rate of false positive results relative to true positive results may be higher, as it depends on the community risk of HIV acquisition over a short time period (i.e., the 6 months between first- and third-trimester testing).
For any positive HIV screen late in pregnancy or during labor, an HIV RNA assay should be done at the same time as the supplemental HIV-1/HIV-2 antibody differentiation assay, as the HIV RNA assay will be needed to resolve questions raised by discordant results between the antigen/antibody screen and the antibody differentiation assay.
The combination of a positive HIV antigen/antibody screen with a negative supplemental HIV-1/HIV-2 antibody differentiation assay and a negative HIV RNA assay is seen in people without HIV who have a false-positive antigen/antibody screen.
Repeat HIV Testing in the Third Trimester
Repeat HIV testing during the third trimester, before 36 weeks gestation, is recommended for people with negative results on their initial HIV tests during pregnancy who—
- Are at high risk of acquiring HIV (e.g., those who inject drugs or have sex with people who inject drugs, those who exchange sex for money or drugs, those who are sex partners of individuals with HIV, those who have had a new sex partner or more than one sex partner during the current pregnancy,2 or those who have a suspected or diagnosed STI during pregnancy)27; or
- Are receiving health care in facilities where prenatal screening identifies one or more pregnant women with HIV per 1,000 women screened, or reside in a jurisdiction that has a high incidence of HIV in women between the ages of 15 and 45 years (see the 2006 Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings [PDF] );2,27 or
- Reside in states or territories with statutes or regulations that require third-trimester testing. In a 2020 article, these included Arkansas, Connecticut, Delaware, Florida, Georgia, Illinois, Louisiana, Maryland, Nevada, New Jersey, North Carolina, Tennessee, Texas, Virginia, and West Virginia.28 Clinicians should check current requirements in their jurisdictions; or
- Have signs or symptoms of acute HIV (e.g., fever, lymphadenopathy, skin rash, myalgia, headaches, oral ulcers, leukopenia, thrombocytopenia, elevated transaminase levels).2,27,29-31
In addition, third-trimester testing should be offered to pregnant people who perceive themselves as being at increased risk for HIV infection (regardless of whether or not they fit any of the above criteria). Pregnant people who decline testing earlier in pregnancy should be offered testing again during the third trimester.
An antigen/antibody immunoassay should be used for third-trimester testing because these tests have a higher sensitivity in the setting of acute HIV infection than older antibody tests.15,32 If acute HIV infection is suspected, a plasma HIV RNA assay should be performed in conjunction with an antigen/antibody immunoassay. See Early (Acute and Recent) HIV Infection for more information.
Providers should be proactive in assessing a pregnant person’s HIV acquisition risk and implementing third-trimester HIV retesting when indicated. A study in Baltimore found that only 28% of women were retested for HIV despite the high incidence of HIV in Maryland and a high frequency of clinical risk factors.10 A study of data from 2007 to 2014 on children in Florida with perinatal HIV exposure found that perinatal HIV transmission was associated with poor or late prenatal care, diagnosis of HIV during labor and delivery or after birth, and, in some cases, acute maternal infection (as indicated by negative results for initial tests).33 In a more recent study from a high-prevalence area in Florida, 91.7% of women had first- or second-trimester screening and, although only 82.2% had a third-trimester test, 89.3% of those without third-trimester screening had rapid testing upon admission.34
HIV Testing During Labor in People With Unknown HIV Status
People in labor whose HIV status is undocumented and those who tested negative early in pregnancy but are at increased risk of HIV infection and were not retested in the third trimester should undergo expedited HIV testing to identify HIV infection in pregnant persons and HIV exposure in their infants.2-4,23,30,35,36
- Perform an expedited HIV test—either an antigen/antibody immunoassay that can provide results within 1 hour or the most sensitive rapid test (includes rapid POC tests) available for persons in labor. An HIV RNA assay should also be performed for individuals with suspected acute HIV infection.
- If the initial HIV test result is negative (nonreactive), no further testing is required unless acute HIV infection is suspected (see Acute HIV Infection During Pregnancy or Breastfeeding below).15
- A positive antigen/antibody immunoassay or rapid HIV test result must be immediately followed by a supplemental HIV-1/HIV-2 antibody differentiation assay, as well as an HIV RNA assay for the mother and an HIV RNA assay for the infant.15 If possible, contact the laboratory to prioritize results.
- For delivery units, every effort should be made to have the ability to run a confirmatory supplemental test (HIV-1/HIV-2 antibody differentiation assay) seven days a week. If possible, results of HIV RNA assays should be available in 24 hours or less.
- For individuals with a positive HIV test result or suspected acute HIV infection during labor, provide counseling about HIV test results and implications for care.
- Initiate IV zidovudine during labor; see Intrapartum Care for People With HIV
- Immediately initiate an ARV regimen that is appropriate for infants who are at high risk of perinatal HIV transmission (see Antiretroviral Management of Newborns With Perinatal HIV Exposure or Perinatal HIV or contact the National Clinician Consultation Center Perinatal HIV/AIDS hotline).
- For persons who were planning to breastfeed, breastmilk should be expressed and stored appropriately until all supplemental HIV test results are reviewed and negative.
HIV Testing During the Postpartum Period
People who have not been tested for HIV before or during labor should be offered expedited testing during the immediate postpartum period. Postpartum HIV testing should be done using the antigen/antibody immunoassay to screen for established and acute HIV; results should be obtained in <1 hour. If acute HIV infection is a possibility, then a plasma HIV RNA test should be sent as well. When mothers are unavailable for testing, their newborns should undergo HIV testing to assess perinatal HIV exposure using an antigen/antibody immunoassay. For infants testing positive, an HIV RNA assay should be sent immediately .3,23,30 Postnatal ARV drugs need to be initiated as soon as possible—ideally ≤6 hours after birth—to be effective in preventing perinatal transmission. When an initial HIV test is positive in mothers or infants, it is strongly recommended that clinicians initiate an ARV regimen that is appropriate for infants who are at high risk of perinatal HIV transmission and counsel the mothers against breastfeeding pending the results of supplemental testing, which should include a plasma HIV RNA assay. Breast milk can be expressed while HIV diagnostic testing is being completed, but it should not be given to the infant until testing confirms that the mother is HIV negative (see Antiretroviral Management of Newborns With Perinatal HIV Exposure or Perinatal HIV). If supplemental test results are negative and acute HIV is excluded, infant ARV drugs can be discontinued. In the absence of ongoing maternal HIV exposure, breastfeeding can be initiated.
Consultation with a pediatric HIV specialist is strongly recommended if questions remain about the potential for acute maternal infection or ongoing maternal HIV exposure.
Infant HIV Testing When Maternal HIV Test Results Are Unavailable
When maternal HIV test results are unavailable (e.g., the mother has declined testing during pregnancy or for infants and children who are in foster care) or their accuracy cannot be evaluated (e.g., for internationally adopted infants and children), HIV testing of these infants or children is indicated to identify HIV exposure and possible infection.3 The choice of test will vary based on the age of the child (see Diagnosis of HIV Infection in Infants and Children). Mechanisms should be developed to facilitate prompt HIV screening for infants who have been abandoned and who are in the custody of the state.
Acute HIV Infection During Pregnancy or Breastfeeding
Australian healthcare providers can refer to The Optimal Scenario & Context Of Care: Guidance For Healthcare Providers Regarding Infant Feeding Options For People Living With HIV for guidance on infant feeding.
Women are more susceptible to HIV infection during pregnancy and the early postpartum period.37 Risk of HIV exposure should be assessed in all people who are considering becoming pregnant, as well as in all pregnant and postpartum people who previously tested negative for HIV, including those who are breastfeeding. People with risk factors for HIV acquisition before, during, and after pregnancy should receive prevention counseling and appropriate interventions, including PrEP if indicated.37,38 (See Prepregnancy Counseling and Care for Persons of Childbearing Age with HIV and Pre-Exposure Prophylaxis (PrEP) to Prevent HIV During Periconception, Antepartum, and Postpartum Periods for more information. People who have acute HIV during pregnancy or lactation have an increased risk of perinatal transmission and secondary sexual transmission of HIV (see Early (Acute and Recent) HIV Infection).39-43 The antigen/antibody immunoassay will detect acute HIV infection earlier than other immunoassays—within approximately 18 days of acquisition. When acute HIV infection is suspected, a plasma HIV RNA test should be sent as well because virologic tests can detect the presence of HIV approximately 5 days earlier than the antigen/antibody immunoassay.
People with possible acute HIV infection who are breastfeeding should cease breastfeeding immediately until HIV infection is confirmed or excluded.44 Breast milk can be expressed while HIV diagnostic testing is completed. Breastfeeding can resume if HIV infection is excluded and there is no ongoing risk. Care of pregnant or breastfeeding people with acute or early HIV, and their infants, should follow the recommendations in the Perinatal Guidelines (see Early (Acute and Recent) HIV Infection, Antiretroviral Management of Newborns With Perinatal HIV Exposure or HIV Infection, and Infant Feeding for Individuals With HIV in the United States).
Clinicians should be aware of public health surveillance systems and regulations that may exist in their jurisdictions for reporting infants who have been exposed to HIV; this is in addition to mandatory reporting of people with HIV, including infants. Reporting infants who have been exposed to HIV allows the appropriate public health functions to be accomplished.
- Nesheim SR, FitzHarris LF, Mahle Gray K, Lampe MA. Epidemiology of perinatal HIV transmission in the United States in the era of its elimination. Pediatr Infect Dis J. 2019;38(6):611-616. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30724833.
- Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1-17; quiz CE11-14. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16988643.
- American Academy of Pediatrics Committee on Pediatric AIDS. HIV testing and prophylaxis to prevent mother-to-child transmission in the United States. Pediatrics. 2008;122(5):1127- 1134. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18977995.
- Chou R, Cantor AG, Zakher B, Bougatsos C. Screening for HIV in pregnant women: systematic review to update the 2005 U.S. Preventive services task force recommendation. Ann Intern Med. 2012;157(10):719-728. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23165663.
- American College of Obstetrics and Gynecology: Committee on Obstetric Practice, HIV Expert Work Group. ACOG Committee opinion no. 752: prenatal and perinatal human immunodeficiency virus testing. Obstet Gynecol. 2018;132(3):e138-e142. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30134428.
- US. Preventive Services Task Force, Owens DK, Davidson KW, et al. Screening for HIV infection: US preventive services task force recommendation statement. JAMA. 2019;321(23):2326-2336. Available at: https://www.ncbi.nlm.nih.gov/pubmed/31184701.
- Whitmore SK, Taylor AW, Espinoza L, Shouse RL, Lampe MA, Nesheim S. Correlates of mother-to-child transmission of HIV in the United States and Puerto Rico. Pediatrics. 2012;129(1):e74-81. Available at: http://www.ncbi.nlm.nih.gov/pubmed/22144694.
- Ezeanolue EE, Pharr JR, Hunt A, Patel D, Jackson D. Why are children still being infected with HIV? Impact of an integrated public health and clinical practice intervention on mother- to-child HIV transmission in Las Vegas, Nevada, 2007–2012. Ann Med Health Sci Res. 2015;5(4):253-259. Available at: https://www.ncbi.nlm.nih.gov/pubmed/26229713.
- Taylor AW, Nesheim SR, Zhang X, et al. Estimated perinatal HIV infection among infants born in the United States, 2002–2013. JAMA Pediatr. 2017;171(5):435-442. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28319246.
- Liao C, Golden WC, Anderson JR, Coleman JS. Missed opportunities for repeat HIV testing in pregnancy: implications for elimination of mother-to-child transmission in the United States. AIDS Patient Care STDS. 2017;31(1):20-26. Available at: https://www.ncbi.nlm.nih.gov/pubmed/27936863.
- Boer K, Smit C, van der Flier M, de Wolf F, Athena Cohort Study Group. The comparison of the performance of two screening strategies identifying newly-diagnosed HIV during pregnancy. Eur J Public Health. 2011;21(5):632-637. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21051473.
- Yudin MH, Moravac C, Shah RR. Influence of an “opt-out” test strategy and patient factors on human immunodeficiency virus screening in pregnancy. Obstet Gynecol. 2007;110(1):81-Available at: http://www.ncbi.nlm.nih.gov/pubmed/17601900.
- Olakunde BO, Pharr JR, Adeyinka DA. HIV testing among pregnant women with prenatal care in the United States: an analysis of the 2011–2017 National Survey of Family Growth. Int J STD AIDS. 2020;31(7):680-688. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32538331.
- Koumans EH, Harrison A, House LD, et al. Characteristics associated with lack of HIV testing during pregnancy and delivery in 36 U.S. states, 2004–2013. Int J STD AIDS. 2018;29(12):1225-1233. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29969977.
- Branson BM, Owen SM, Wesolowski LG, et al. Laboratory testing for the diagnosis of HIV infection: updated recommendations. Vol. ed.: Centers for Disease Control and Prevention; 2014.
- Centers for Disease Control and Prevention, Association of Public Health Laboratories. Laboratory testing for the diagnosis of HIV infection: updated recommendations. 2014. Available at: http://dx.doi.org/10.15620/cdc.23447.
- Thomson KA, Hughes J, Baeten JM, et al. Increased risk of HIV acquisition among women throughout pregnancy and during the postpartum period: a prospective per-coital-act analysis among women with HIV-infected partners. J Infect Dis. 2018;218(1):16-25. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29514254.
- Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med. 2011;365(6):493-505. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21767103.
- Baggaley RF, White RG, Hollingsworth TD, Boily MC. Heterosexual HIV-1 infectiousness and antiretroviral use: systematic review of prospective studies of discordant couples. Epidemiology. 2013;24(1):110-121. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23222513.
- Jamieson DJ, Read JS, Kourtis AP, Durant TM, Lampe MA, Dominguez KL. Cesarean delivery for HIV-infected women: recommendations and controversies. Am J Obstet Gynecol. 2007;197(3 Suppl):S96-100. Available at: http://www.ncbi.nlm.nih.gov/pubmed/17825656.
- Tubiana R, Le Chenadec J, Rouzioux C, et al. Factors associated with mother-to-child transmission of HIV-1 despite a maternal viral load <500 copies/mL at delivery: a case- control study nested in the French perinatal cohort (EPF-ANRS CO1). Clin Infect Dis. 2010;50(4):585-596. Available at: http://www.ncbi.nlm.nih.gov/pubmed/20070234.
- Townsend CL, Cortina-Borja M, Peckham CS, de Ruiter A, Lyall H, Tookey PA. Low rates of mother-to-child transmission of HIV following effective pregnancy interventions in the United Kingdom and Ireland, 2000–2006. AIDS. 2008;22(8):973-981. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18453857.
- Havens PL, Mofenson LM, American Academy of Pediatrics Committee on Pediatric AIDS. Evaluation and management of the infant exposed to HIV-1 in the United States. Pediatrics. 2009;123(1):175-187. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19117880.
- Hegazi A, Forsyth S, Prime K, BASHH Adolescent Special Interest Group. Testing the children of HIV-infected parents: 6 years on from ‘don’t forget the children.’ Sex Transm Infect. 2015;91(2):76-77. Available at: http://www.ncbi.nlm.nih.gov/pubmed/25316913.
- Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents with HIV. National Institutes of Health, Centers for Disease Control and Prevention, HIV Medicine Association, and Infectious Diseases Society of America. 2022. Available at: https://clinicalinfo.hiv.gov/en/guidelines/adult-and- adolescent-opportunistic-infection.
- American College of Obstetricians and Gynecologists, Committee on Obstetric Practice HIV Expert Work Group. ACOG committee opinion no. 752: prenatal and perinatal human immunodeficiency virus testing. Obstet Gynecol. 2018;132(3):e138-e142. Available at: https://www.ncbi.nlm.nih.gov/pubmed/30134428.
- Salvant Valentine S, Caldwell J, Tailor A. Effect of CDC 2006 revised HIV testing recommendations for adults, adolescents, pregnant women, and newborns on state laws, 2018. Public Health Rep. 2020;135(1_suppl):189S-196S. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32735201.
- Sansom SL, Jamieson DJ, Farnham PG, Bulterys M, Fowler MG. Human immunodeficiency virus retesting during pregnancy: costs and effectiveness in preventing perinatal transmission. Obstet Gynecol. 2003;102(4):782-790. Available at: http://www.ncbi.nlm.nih.gov/pubmed/14551009.
- American College of Obstetrics and Gynecology: Gynecology Committee on Obstetric Practice. ACOG committee opinion no. 418: prenatal and perinatal human immunodeficiency virus testing: expanded recommendations. Obstet Gynecol. 2008;112(3):739-742. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18757690.
- Richey LE, Halperin J. Acute human immunodeficiency virus infection. Am J Med Sci. 2013;345(2):136-142. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23095473.
- Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in adults and adolescents living with HIV. 2019. Available at: https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent- arv/whats-new-guidelines.
- Trepka MJ, Mukherjee S, Beck-Sague C, et al. Missed opportunities for preventing perinatal transmission of human immunodeficiency virus, Florida, 2007–2014. South
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- Szlachta-McGinn A, Aserlind A, Duthely L, et al. HIV screening during pregnancy in a U.S. HIV epicenter. Infect Dis Obstet Gynecol. 2020;2020:8196342. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32454582.
- Yee LM, Miller ES, Statton A, et al. Sustainability of statewide rapid HIV testing in labor and delivery. AIDS Behav. 2018;22(2):538-544. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28986656.
- Scott RK, Crochet S, Huang CC. Universal rapid human immunodeficiency virus screening at delivery: a cost-effectiveness analysis. Infect Dis Obstet Gynecol. 2018;2018:6024698. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29731602.
- Thomson KA, Hughes J, Baeten JM, et al. Increased risk of HIV acquisition among women throughout pregnancy and during the postpartum period: a prospective per-coital- act analysis among women with HIV-infected partners. J Infect Dis. 2018;218(1):16-25. Available at: https://www.ncbi.nlm.nih.gov/pubmed/29514254.
- Graybill LA, Kasaro M, Freeborn K, et al. Incident HIV among pregnant and breast- feeding women in sub-Saharan Africa: a systematic review and meta-analysis. AIDS. 2020;34(5):761-776. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32167990.
- Lockman S, Creek T. Acute maternal HIV infection during pregnancy and breast- feeding: substantial risk to infants. J Infect Dis. 2009;200(5):667-669. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19627246.
- Taha TE, James MM, Hoover DR, et al. Association of recent HIV infection and in-utero HIV-1 transmission. AIDS. 2011;25(11):1357-1364. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21572305.
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